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Obama faced major reluctance on the part of insurance companies to join and remain in the Health Insurance Exchange. A last ditch agreement funded by what was yet to be approved congressional approval of a budgetary allotment.

Panic prompted ObamaCare lawlessness

By Doug BadgerThe Hill, July 15, 2016

Senior Obama administration officials took a series of decisions beginning in late 2013 that ranged from the reckless to the illegal in an effort to keep insurers participating in health insurance exchanges.

A report issued last week jointly by the House Ways and Means and Energy and Commerce committees explores how the administration came to unlawfully funnel $7 billion in unappropriated money to insurers through a single ObamaCare program.

The program — known as cost-sharing reduction (CSR) — requires insurers to reduce deductibles and other out-of-pocket spending for certain low-income people who signed up for coverage through health insurance exchanges. In turn, the statute authorized the administration to seek an appropriation from Congress to reimburse insurers for the cost of providing these coverage enhancements.

The congressional report chronicles how the administration determined as early as 2010 that it needed an appropriation to make CSR payments to insurers. In April 2013, the president submitted a budget to Congress formally requesting the appropriation.

But in July, the Senate Appropriations Committee, then controlled by Democrats, expressly denied the president's request. Sometime after Congress refused to fund the program, the administration contrived the theory that it could spend money without an appropriation.

Senior officials at the Office of Management and Budget (OMB) drafted a legal memorandum during late 2013 declaring that the government could make billions in CSR payments to the insurance industry without congressional approval. The administration began making the unlawful payments in January 2014.

Although the administration continues to stonewall the congressional investigation into how it arrived at this decision, the committees have learned that several Treasury Department officials raised concerns about the OMB memo. Those officials were permitted to read the document, but were forbidden to make copies or take notes.

The administration has denied Congress even that courtesy, defying congressional subpoenas for copies of the OMB memorandum and other material relevant to the investigation. It has supplied them with a memorandum that Treasury Secretary Jack Lew signed in January 2014 directing his subordinates to begin making CSR payments. But that memorandum has been redacted to omit the department's legal justification.

The administration also has slapped a gag order on current and former employees, instructing them not to answer the committees' questions about the legality of the unappropriated spending.

The administration's defiance has a much simpler explanation: Its actions have no legal basis. Even The New York Times has acknowledged that if the administration were permitted to continue spending unappropriated money, "it could have major — some might say huge — consequences for our constitutional democracy."

At least one federal judge agrees. In a lawsuit filed by the House of Representatives, Federal District Court Judge Rosemary Collyer in May ruled that the CSR payments were unlawful. The Justice Department has appealed Collyer's ruling.

My July 8 testimony before the House Energy and Commerce Subcommittee on Oversight and Investigations showed how the government's unlawful spending on the CSR program fits into a broader pattern of malfeasance in ObamaCare implementation. That malfeasance includes decisions made during the first half of 2014 to unlawfully divert $3.5 billion to $4.5 billion from the Treasury to insurance companies through the "reinsurance" program. It also involves the attempt by the government to turn the law's "risk corridor" program into a new version of the Troubled Asset Relief Program (TARP), forcing taxpayers to cover losses resulting from bad business decisions made by insurance executives.

Those abrupt and unlawful policy reversals were occasioned by a serious miscalculation of demand for health insurance among relatively healthy people.

It turns out that millions don't want it, unless premiums are steeply discounted. ObamaCare does the opposite for people in relatively good health, requiring insurers to overcharge them for a product they may not want or need, while discounting premiums for those in poorer health.

The result is a dysfunctional "market" that attracts high-risk enrollees and repels low-risk ones, leaving insurers with a losing proposition: a pool of customers who are disproportionately older, less well and paying premiums that are too low to cover their medical bills.

When the consequences of this dysfunctionality dawned on the administration, panic set in, prompting a series of regulatory improvisations providing for the payment of billions in corporate subsidies to the insurance industry.

Although the administration is not especially fond of insurers (as the president demonstrated this week with his renewed embrace of the "public option"), the exchanges would collapse without them. To avoid the political embarrassment of insurers withdrawing en masse from the exchanges, it has chosen to supply them with unlawful payments and stonewall congressional inquiries into this misconduct.

The administration's actions raise concerns that transcend the fractious politics of ObamaCare: They are institutional and constitutional in nature. Institutional because Congress's core lawmaking and oversight functions are being effaced. Constitutional because its power of the purse is under legal assault.

In such circumstances, Congress cannot be passive. It must act to require the administration to follow the law.

Badger, a former White House and U.S. Senate policy adviser, is a senior fellow with the Galen Institute. This piece was adapted from his July 8 testimony before the House Energy and Commerce Subcommittee on Oversight and Investigations.

Now and then I share the experiences physicians witness, even in their own nor family's care. For them it is also a challenge. Pity the ordinary patient citizen.

I received an email from Doximity, a closed professional social media site restricted to physicians. On Doximity we all share elevator talk...the few seconds of intercourse discussing patient experiences among peers. (probably illegal under the shield of HIPAA regulations. These regulations have become more than burdensome, because they do effect patient care.

This story spells out one or more such situations a physician experiences in his own care or that of a friend or family. This process consumes an inordinate amount of time during an appeal process. One case in particular concerning a serious lumbar disc illuminates the tension of reading a guideline of prior treatment pursuant to approving a request for an MRI. MRIs by the way are considered standard practice for serious back injuries. Prolonged herniated disc problems often lead to permanent nerve injury and disability.The insurance company insisted on a six week waiting period before an MRI was approved. Their decision is based upon the fact and MRI costs $ 1,000, not the welfare of a patient.

From a Medical-legal standpoint this places the physician in jeopardy, despite his order for an MRI. Had the patient presented at an emergency department an MRI most likely would have been ordered. And since it was in an acute emergent condition it would have been pefrormed immediately and without a prior authorization. The risk of a legal incident in the emergency setting would pre-empt any decision by the insurer. The hospital or MRI center would be the loser if an insurer retroactively did not authorize a payment. (they do not like losing money with smaller margins.). The insurance company is under control, unless the physician insists using his authority to protect the patient.

This scenario occurs multiple times a day for most MDs. It is a major cause for burnout, which most patients are aware occurs often early in a physician's career.

Many articles now discuss the rising tide of physician burnout, and suicide. How can it be prevented?

The loss of physician authority and the complex tension between advocating for the patient and the bottom line for health insurers creates a conundrum for the doctor. She (he) has been placed in a repeating cycle of conflict, a chronic emotional enui leading to a similar state as PTSD.(post traumatic stress disorder). Only in this case it is not post-traumatic, it is ongoing on a daily basis.

This may be the primary cause for physician burnout and suicide Doctors have been trained to work long hours and to deal with emergencies, even in the middle of the night.

Wednesday, July 13, 2016

Two mega-mergers in the health insurance industry are sparking intense debate over cost and competition.

California has two health insurane regulatory agencies: 1. Commissioner Dave Jones, and 2.Shelley Roullaard and the Dept of Managed Health Care. The Department of Manged Health Care came into existence about 20 years ago when the boom in HMOs occured.

California Insurance Commissioner Dave Jones has criticized both deals — Anthem-Cigna andAetna-Humana — as being anti-competitive, and he has asked the U.S. Department of Justice to block the mergers on antitrust grounds. Jones has questioned whether policyholders will see much of the savings these companies tout in their proposed acquisitions.

But California’s other insurance regulator, Shelley Rouillard at the Department of Managed Health Care, approved the Aetna deal with a condition that the company try to keep future rate increases to a minimum. She hasn’t weighed in on Anthem’s merger.

Meanwhile, another key regulator reviewing the deals — Connecticut Insurance Commissioner Katharine Wade — has come under scrutiny because of her extensive ties to Cigna.

Chad Terhune of California Healthline discussed these developments, and the potential impact of industry mergers on consumers and market competition, last Friday on WNPR’s “Where We Live” in Connecticut.

Key regulators disagree in approving these consolidations. Some who are smaller insurers or those forming new entities say there is adequate competition in the market place.

Two mega-mergers in the health insurance industry are sparking intense debate over cost and competition.

California has two health insurane regulatory agencies: 1. Commissioner Dave Jones, and 2.Shelley Roullaard and the Dept of Managed Health Care. The Department of Manged Health Care came into existence about 20 years ago when the boom in HMOs occured.

California Insurance Commissioner Dave Jones has criticized both deals — Anthem-Cigna andAetna-Humana — as being anti-competitive, and he has asked the U.S. Department of Justice to block the mergers on antitrust grounds. Jones has questioned whether policyholders will see much of the savings these companies tout in their proposed acquisitions.

But California’s other insurance regulator, Shelley Rouillard at the Department of Managed Health Care, approved the Aetna deal with a condition that the company try to keep future rate increases to a minimum. She hasn’t weighed in on Anthem’s merger.

Meanwhile, another key regulator reviewing the deals — Connecticut Insurance Commissioner Katharine Wade — has come under scrutiny because of her extensive ties to Cigna.

Chad Terhune of California Healthline discussed these developments, and the potential impact of industry mergers on consumers and market competition, last Friday on WNPR’s “Where We Live” in Connecticut.

Key regulators disagree in approving these consolidations. Some who are smaller insurers or those forming new entities say there is adequate competition in the market place.

Two mega-mergers in the health insurance industry are sparking intense debate over cost and competition.

California has two health insurane regulatory agencies: 1. Commissioner Dave Jones, and 2.Shelley Roullaard and the Dept of Managed Health Care. The Department of Manged Health Care came into existence about 20 years ago when the boom in HMOs occured.

California Insurance Commissioner Dave Jones has criticized both deals — Anthem-Cigna andAetna-Humana — as being anti-competitive, and he has asked the U.S. Department of Justice to block the mergers on antitrust grounds. Jones has questioned whether policyholders will see much of the savings these companies tout in their proposed acquisitions.

But California’s other insurance regulator, Shelley Rouillard at the Department of Managed Health Care, approved the Aetna deal with a condition that the company try to keep future rate increases to a minimum. She hasn’t weighed in on Anthem’s merger.

Meanwhile, another key regulator reviewing the deals — Connecticut Insurance Commissioner Katharine Wade — has come under scrutiny because of her extensive ties to Cigna.

Chad Terhune of California Healthline discussed these developments, and the potential impact of industry mergers on consumers and market competition, last Friday on WNPR’s “Where We Live” in Connecticut.

Key regulators disagree in approving these consolidations. Some who are smaller insurers or those forming new entities say there is adequate competition in the market place.

Disclaimer

The opinions in this blog or other forms of social media are solely that of Gary M. Levin M.D. Dr. Levin has no financial interests in any medical devices which are discussed or which appear in the blog. Commentary taken from other sources are either quoted or referenced with attribution. Dr Levin does not endorse, nor give financial support to any political organizations.